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Please take a few moments to fill out the four sections of this online form as completely as you can. We look forward to working with you in maintaining your dental health. After completing this form, please click on the "submit" button at the end of the form. Your information will then be e-mailed to our office.

Section 1 - General Data

Today's Date

Last Name

First Name

Middle Intl.

Prefer To Be Called

Address - Street

Address - City - State - Zip

Home Phone Number

Cell Phone Number

Pager Number

Email Address

The following personal information will help us to give you the most consideration of your time and feelings. It is important to have complete answers. All information is, of course, considered confidential.

Occupation

Social Security Number

Date Of Birth

Employer

Business Telephone and Extension

Business Address - Street

Business Address - City - State - Zip

If Student, School Name

Please Select One: Single Married Widowed Separated Divorced

Spouse's First Name

Spouse's Social Security Number

Occupation Of Spouse

Spouse's Employer

Spouse's Business Address - Street

Spouse's Business Address - City - State - Zip

Spouse's Business Telephone Number - Extension

Physician's Name

Physician's Address

Physician's Telephone Number

Person responsible for payment of bill

If you are under 18, or not responsible for payment of bill

Name

Mother's Name

Mother's Occupation

Mother's Telephone

Mother's Social Security Number

Mother's Employer

Father's Name

Father's Occupation

Father's Telephone

Father's Social Security Number

Father's Employer

Section 2. Insurance Information

Are you covered by any kind of dental insurance? Select one please: Yes No

Name of insurance company

Name of Employer

Address of Insurance Company

Address of Insurance Company

Name of Subscriber

Group Number

Birthdate

Dependents

1. Name - Birthdate

2. Name - Birthdate

3. Name - Birthdate

4. Name - Birthdate

Section 3. Dental And Family History

Are you aware of any particular dental problems?

Are you having any discomfort or pain?

Have you ever had any problems with your Temporomandibular (Jaw) Joint? Yes No

If yes, describe

Do you regularly wake up with headaches? Yes No

Do you have insomnia? Yes No

Do you snore? Yes No

How long has it been since you last visited a dental office?

What was done for you at that time?

May we ask who recommended this office?

Do you have family history of: Heart Disease T.B. Diabetes Cancer High Blood Pressure

Do you smoke? Yes No

If so, what and how much / Day

How often do you consume alcoholic beverages? Check One (Per Week) None 1-5 Drinks Per Week 6-10 10 or more

Present health status of immediate family

Which, if any, sports activities do you regularly participate in?

Has there been a problem in your general health within the past 5 years? Yes No

If yes, please explain

Date of last physical exam?

Are you currently under the care of a physician? Yes No

If yes, please explain

Are you currently taking any drug or medicine? Yes No

If so, what?

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING DISEASES OR PROBLEMS, PLEASE SELECT YES OR NO. PLEASE CHECK THE DISEASE OR ILLNESS THAT APPLIES TO YOU.

Mitral Valve Prolapse. Yes No

Heart Murmur. Yes No

Rheumatic fever, rheumatic heart disease. Yes No

Other heart trouble, heart attack, High Blood Pressure, Stroke. Yes No

Pain in chest, shortness of breath, swollen ankles. Yes No

Are you wearing a Pacemaker? Yes No

Do you have any type of joint replacement? Yes No

If yes, what?

Has your physician ever suggested that you have antiiotic premedication for dental procedures? Yes No

Blood disorders, anemia? Yes No

Blood tests with unusual results? Yes No

Abnormal bleeding, prolonged healing, bruises easily? Yes No

Low blood pressure? Yes No

Fainting spells, seizures or epilepsy? Yes No

Hepatitis, jaundice, liver disease? Yes No

Arthritis? Yes No

Kidney troubles? Yes No

If yes, what?

Have you ever been told you are HIV positive? Yes No

Has a member of the medical profession diagnosed you as having or treated you for Acquired Immune Deficiency Syndrome (AIDS)? Yes No

Sensitive or allergic to: (Check all that apply) Penicillin Sulfa Novocain Codeine Aspirin Anesthetics

Other

Sensitive or allergic to any metals, jewelry? Yes No

Sensitive or allergic to any foods? Yes No

What?

Do you have stomach ulcers? Yes No

Are you wearing contact lenses? Yes No

Do you have any other diseases or problems? Yes No

If so, what?

Women are you pregnant? Yes No

Persistent cough, cough up blood? Yes No

Radiation, surgery, or drug treatment for a tumor or growth? Yes No

Sores that did not heal within one week? Yes No

Tuberculosis, other lung ailments? Yes No

If so, what?

Diabetes? Yes No